a mother

So you don't want to let him go. "Brain dead." They all file in, in groups of two or three, somber faced, long white coats. Nurses touch your shoulders in the hallway, they speak to you in low tones. Slow, measured words. Your child, your child, he is gone. In every meaningful way, gone. But his heart is still beating. Yes, mechanically pumping away, refusing to stop. A machine with no more soul.

You don't want to let go. You've held him all of his 23 years. You've bathed him, wiped his forehead, learned to decipher his mouthed words. It was your genes, wasn't it, that did this to him? You have lived your whole life in penance, your devotion to him is your self-flagellation, it is your salvation. Don't take it away, you think, because then what?

I'll tell you "then what". Then you cry, you cry for weeks, months even. You save things that were his, touch them, sleep with them, smell them. You throw yourself into his remembrance. You shop for grave stones. You spend hours at a cemetery, staring at his name on the stone, not sure how you got here, who you are, why the name is there, and not on report cards, or drivers licenses, or passports instead. You will beg, each night before sleep, beg and plead for the universe to undo it. Make it go away. You will count each minute, each hour, each day since you last touched him. You will live on, showering, dressing, wiping the kitchen table, spooning food into your own mouth. You will just keep going even when he has not, and that is terrible. Truly terrible.

Herniated. We say the words. Herniated. We equate it with death. We have already decided. But you hear a heartbeat, you want to keep listening, you want to be able to reach out and touch his warm skin. They pronounce him "brain dead". After much delicate handling, they finally tell you that they will not prolong him in this state. They will not. They bring the imam. They bring the ethics committee. They bring the patient relations representative. You call every hospital in the area. Keep my child alive, even if he's not really living, you beg.

We shake our heads, we mutter "crazy" under our breaths. Everyone is fed up, absolutely fed up, of this carrying on, this refusal to face reality.

How glad I am that I did not have to say, "yes, go ahead, withdraw". The choice was taken from me, and I'm grateful. I understand you. I want you to change your mind, but I understand you.

Peace of the universe to you, mother.

highlights of my day(s)

1) The other day one of our patient's needed an emergent ex-lap (exploratory laparotomy) for abdominal compartment syndrome, so the ICU room was turned into a temporary OR. And we all wanted to watch.
2) The GI and Surgery consulting teams spent a whole day contradicting each other and sabatoging each other's plans. The ICU team got her extubated and off pressors. Consulting teams: get along or get out!

3) The patient in the above scenario spoke Chaldean, which is a dialect of Arameic, which as you can imagine, is not a widely spoken language in these parts. In fact, it is spoken only by certain natives of Kurdistan and its diaspora. My other patient spoke Spanish. I speak neither.
4) I'm excited because my hero, friend, and favorite doctor of all-time is on the Palliative Care team, and my patient needs a palliative care consult. I know, I know, it's all about me.
5) Is anything better than a physician's permission to NOT do a sedation holiday? It's like a get-out-of-jail-free card! (Once again- all about me.)

fellow ICU blogger

Does everyone reading this follow Perspective is a Lovely Hand to Hold?c

This blogger is an ICU nurse who can really articulate the gravity of what we face in the life and death situations that make up our "mundane" work day.

This is not only my favorite nursing blog, but one of my favorite blogs period.

the maybe-ECMO patient gets lungs!

Maybe-ECMO patient is now Lung Transplant patient, after a day and a half of having ECMO (while I was off), he was called to the OR to receive his new lungs at 2am. We are following the board, watching for him to return to TICU.

Interesting facts about lung transplants:
Survival rate after 5 years: 50%
Survival rate at 10 years: 28%
Transplanted lungs typically begin to fail after 5 years, and typically fail completely at 10 years.

A single lung transplantation takes 6-8 hours, a double lung transplant can take up to 12 hours.

The single most common reason (27%) for lung transplantation is emphysema. IPF (such as what this patient has) is the reason for a transplant 16% of the time.

Patients, even vented or ECMO patients, are required to continue to do physical therapy. They cannot have received blood transfusions in the recent past, have no signs or symptoms of any kind of infection, and must be non-smoking, non-drinking, non-drug using, and willing and able to comply with medical instructions.They must fit a psychological profile, have no other chronic disorders of major organs, cannot have hepatitis or HIV, be within the required age range, and have a good social support system.

Here's to hoping Mr. Lung Transplant gets his lungs and everything goes off without a hitch!

patient funnies

Me holding up phone to confused patient's ear: "This is your son. Here you go. Say hi."

Patient, looking straight at me and ignoring the phone: "Hi!"

Me to patient: "No no... on the phone."

Patient, smiling at me: "On the phone."

*sigh*

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Same patient after phone call...

Me to patient: "That was your son, he just wanted to hear your voice."
Patient: "Oh... [pause] Did he hear it?

Me: "Um, yes. He heard it."

Patient: "Good."

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Attending to patient: "Who do you live with at home sir?"

Patient: "Yes... we live together."

Attending: "Who is we? Your wife?"

Patient: "Yes... [pointing at senior, male resident] her and I!"

Heh heh.

mini-live blogging on the maybe-ECMO patient

1200: We thought we had a green light for ECMO. They changed their minds. They want us to oxygenate him with 100% FiO2, then turn the paralytics off and try again. If (when) he tanks, I'll bolus him with vec, the paralytic du jour, and restart the drip. Hopefully, he'll recover. This will prove (at least to ECMO, no one else needs convincing) that he absolutely must get cannulated for ECMO. Then that will happen tomorrow.

If he doesn't improve when I restart the paralytic?
Checkmate.

I don't like playing games like this. I am pushing buttons right now only after clear confirmation from the ICU attending and no one else. I'm not sure the resident and intern feel like this is even their patient.

1300: FiO2 is increased to 100%, will pre-oxygenate him for 30 minutes until turning off the paralytic, which will take up to 30 minutes to wear off. Group huddle with family. I encouraged his wife and daughter to walk around and stretch before the paralytic wears off.

1330: Paralytic off.

1400: Paralytic should be out of his system. Train of Four is 4:4 (four out of four).

1440: ICU Fellow tells us to continue routine care (bath, ET tube tape changes, turns, etc) per usual, if not with an extra degree of caution.

1445: Couging attack begins. I bolus versed and fentanyl. His sats drift into the 80s, he comes back up. I bolus more, repeat. His wife tells him over and over he's ok. Her mantra works. He recovers to the 90s and we don't have to start the vec. I swab the back of his throat with lidocaine and pour lidocaine down his ET tube. We got through this one somehow.

1545: Patient's heartrate suddenly increases to 138 with loss of blood pressure, appears to be afib. Rate then decreases to low 100s, irregular, EKG arrives. Patient in and out of afib/sinus/frequent PACs with intermittent need for pressors.

1645: Patient's secretions are causing him to have low tidal volumes and coughing. We take him off the vent and bag him with a PEEP valve, suctioning intermittently, to remove large amounts of tenacious secretions. Patient desats to 60s, but recovers to 90s within one minute. Victory!

1730: Patient is bathed and ET tube tapes changed without coughing or desatting.

1900: We can't believe we made it to the end of the shift without incident! I leave him with pressors off, satting well, off paralytics. I hug his wife goodbye. I know I'll spend the next few days wondering if he's still alive, and hoping that he gets his lungs.

hours of boredom, minutes of terror

The title refers to the way anesthesiologists describe their job. 

They said yes to ECMO.

It's been two days of exultant highs, white-knuckled lows. You float peacefully along the riverbed we carved out for you, like the dreamers that we are, until you catch, you snag, you tear. You break.

We patch up the hole, we sew the pieces back on. We mend you with tight lips and grim faces. Every victory snatched away from us too soon.

We bolus you over and over to stop your coughing. We watch your pulse ox saturation nose dive and sit at a breath-taking low, the seconds ticking by ever-so-slowly.

Fuck it, I say, I'm restarting paralytics. I reach for the line. Almost as if responding, your sats jump up into the 70s. My finger pauses on the button. The attending appears, and gives me the go ahead. We paralyze you. We pump up your blood pressure with pressors, trying to repair the damage we've done with our other drugs. Your head lolls, rag-doll-like. Behind us, the photos of your life (jet-skis, graduations, and sunny days) seem to call out in sudden pain.

No options, we say to the family. No options, we say to ourselves.

What will happen to you? Can you survive every odd, can you hang on through ECMO, physical therapy, waiting for lungs, and a high-risk surgery?

I want to hope, but somehow... I just don't think so.